Reanalysis of Factors Predicting Recurrent Stenosis in a Prospective Randomized Trial of Carotid Endarterectomy Comparing Primary Closure and Patch Closure

Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.

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Prospective Randomized Trial of Routine vs Selective Shunting in Carotid Endarterectomy Based on Stump Pressure

Journal of Vascular Surgery ◽

10.1016/j.jvs.2009.10.020 ◽

2009 ◽

Vol 50 (6) ◽

pp. 1539

Author(s):

Ali F. AbuRahma ◽

Patrick A. Stone ◽

Stephen M. Hass ◽

L. Scott Dean ◽

Joseph Habib ◽

...

Keyword(s):

Randomized Trial ◽

Carotid Endarterectomy ◽

Prospective Randomized Trial ◽

Stump Pressure

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Long-Term Outcome of Carotid Endarterectomy with Bovine Pericardial Patch Closure: A Comparison to Dacron Patch and Primary Closure

Journal of Vascular Surgery ◽

10.1016/j.jvs.2009.10.076 ◽

2010 ◽

Vol 51 (2) ◽

pp. 532

Author(s):

Karen J. Ho ◽

Matthew T. Menard

Keyword(s):

Carotid Endarterectomy ◽

Primary Closure ◽

Pericardial Patch ◽

Term Outcome ◽

Long Term Outcome ◽

Bovine Pericardial Patch ◽

Patch Closure ◽

Dacron Patch

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Results of Carotid Endarterectomy Using Bovine Pericardium Patch Closure, with a Review of Pertinent Literature

The American Surgeon ◽

10.1177/000313481608200315 ◽

2016 ◽

Vol 82 (3) ◽

pp. 221-226 ◽

Cited By ~ 4

Author(s):

Stephen B. Olsen ◽

William C. Mcquinn ◽

Philip Feliciano

Keyword(s):

Literature Review ◽

Carotid Endarterectomy ◽

Postoperative Bleeding ◽

Bovine Pericardium ◽

Carotid Surgery ◽

Pertinent Literature ◽

Recurrent Stenosis ◽

Symptomatic Disease ◽

Handling Characteristics ◽

Patch Closure

Patch closure after carotid endarterectomy lowers risk of recurrent stenosis and perioperative neurologic events. Although vein patches have theoretic benefits, few differences between vein and nonautologous patches have been noted. Bovine pericardium has been increasingly used in carotid surgery over the last 15 years, with favorable reports. This study reviews a large carotid surgery series using this patch. Data were gathered on 464 consecutive carotid operations using the bovine pericardium patch; all complications were analyzed and pertinent literature review was performed. Of 464 procedures, 218 (47%) were performed for symptomatic disease. Total peri-operative ipsilateral stroke rate was 0.65 per cent. A low rate of postoperative bleeding was noted. Recurrence of >70 per cent stenosis was 1.6 per cent at follow-up of 26 months in 410 patients. Handling was subjectively described as excellent. Literature review comprising 3239 carotid operations revealed low risks of stroke, bleeding requiring intervention, or high rates of recurrent stenosis. Bovine pericardium patch angioplasty has low perioperative and late complications and good handling characteristics, making it an acceptable choice for use in carotid surgery.

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Carotid Endarterectomy With Primary Closure Does Not Adversely Affect the Rate of Recurrent Stenosis

Archives of Surgery ◽

10.1001/archsurg.1994.01420300092016 ◽

1994 ◽

Vol 129 (6) ◽

pp. 648 ◽

Cited By ~ 35

Author(s):

Hugh A. Gelabert

Keyword(s):

Carotid Endarterectomy ◽

Primary Closure ◽

Recurrent Stenosis

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Abstract 115: Is Routine Patching Necessary Following Carotid Endarterectomy (CEA)?

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.36.suppl_1.115 ◽

2016 ◽

Vol 36 (suppl_1) ◽

Author(s):

Nicholas J Gargiulo

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Retrospective Review ◽

Primary Closure ◽

Perioperative Stroke ◽

Symptomatic Carotid ◽

Significant Difference ◽

Patch Closure ◽

Closure Group

Objectives: Large medicare databases and meta-analyses recommend routine patching following carotid endarterectomy (CEA). Routine patching reduces perioperative stroke, carotid thrombosis, and restenosis. This 30 year experience evaluates the long term outcome of CEA with selective patching and without routine postoperative duplex examination. Methods: An IRB-approved retrospective review of all CEAs peformed by two surgeons over a 30 year period (1984-2014). Pre-operative imaging studies, operative reports, physical findings, co-morbid conditions, and pre- and postoperative medications were evaluated. Results: Over a 30-year period, 439 CEAs were performed for symptomatic carotid disease using a selective patch technique depending on gender, internal carotid artery diameter, cardiovascular risk factors, and preoperative arteriogram. In this group of 439 patients, 17 (3.9%) had patch closure of the carotid artery and the other 422 (96.1%) had primary closure. There were 2 (0.47%) perioperative strokes in the primary closure group and 4 (0.95%) patients in this group developed symptomatic carotid restenosis at a mean follow-up of 49.5 months (range 1 to 237 months). There was 1 (5.8%) carotid thrombosis in the patch closure group who also had a perioperative stroke and was serologically positive for a hypercoagulable disorder. The 4 patients who developed symptomatic restenosis had arteriographically proven > 90% stenosis and required repeat CEA. The remaining 418 (99.0%) patients having primary closure remained neurologically asymptomatic (mean follow-up 10.3 years, range 2.5 to 17 years). There was 1 (0.23%) operative death that occurred following the induction of general anesthesia. Conclusions: In this experience, there is no statistically significant difference in restenosis in the primary closure group and selective patch group following CEA. Although this data set is a small, single center, two surgeon, retrospective review, it does not support the generally well accepted view of routine patching following CEA

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